Chapter 41 — You're Still a Pain in the Ass, Loucks!

_August 24, 1989, McKinley, Ohio_

{psc} "Julie Perez, twenty-six," I said. "Presents with a complaint of numbness and tingling in her left foot, with onset early this morning. Pulse 76; BP 110/70; temp 36.7°C. No other complaints. Nothing remarkable on exam; nothing remarkable in the blood work. No motor or reflex impairment, but a neuropathy test showed lack of sensation for five touches on her lower leg, three on her big toe, and two on the ball of her foot. Moderately active with no family history of neuropathic disease."

"Hi, Julie, I'm Doctor Lucy Vanderberg from neurology. I'm going to examine you, and very likely ask some of the same questions Doctor Mike asked."

It had actually been Al, but there was no point in correcting that, as I'd listened to the entire exchange and Al had done a very good job.

"OK," Julie agreed.

Lucy performed her exam, including a neuropathy test, confirming my findings.

"Mike," Doctor Vanderberg said, "let's get a complete set of x-rays from the knee down, on both legs. I'll review those before we decide next steps."

"What do you think is wrong?" Julie asked.

"The most likely cause of the symptoms you're exhibiting is compression neuropathy, that is, something pressing on a nerve in your leg. The x-rays are to rule out a cyst or other condition that might cause it. If the x-rays are negative, we'll try soft-tissue treatment, which, in layman's terms, is massage therapy, as muscle tension or tightness can cause the symptoms you're experiencing. I'll come back and see you once we have the x-rays."

"Thanks."

"Mike, call me when you have the films."

"Will do," I replied. "Thanks, Lucy. Julie, I'll make the arrangements and be right back."

I followed Doctor Vandenberg from the treatment room, electing to make the call from the clerk's desk as otherwise I'd have been alone with Julie. I called Radiology and arranged for the x-rays, then called for an orderly. I asked Kellie to join me, then went back into the treatment room to let Julie know that an orderly would take her to Radiology in a wheelchair.

I left the room and returned to check on Mr. Nylander. His labs were back, and showed no elevated cardiac enzymes which strongly suggested he hadn't had a heart attack, and when combined with the EKG, indicated either unstable angina or atherosclerosis. That meant a toss-up of a cardiac consult or referring him to his personal physician and advising him to see a cardiologist.

I had a very strong feeling that I could safely street him, but the last thing I wanted was a bounceback MI caused because his arteries were seriously occluded. The counterargument was that he wasn't having an MI, and could reasonably safely schedule a non-emergency stress test and cardiac echo.

"I don't see any signs of a heart attack," I said to him. "Your cardiac enzymes are normal, as is your EKG. Give me ten minutes to confer with a colleague, and I'll let you know the next steps."

"Mind telling me what you think?"

"Not at all. The two most likely diagnoses are unstable angina or atherosclerosis, and those aren't mutually exclusive. Both are treatable, and neither of them are immediately life-threatening. The options are admitting you for further testing or releasing you with instructions to see your personal physician and a cardiologist. My inclination is for the latter, because you'll be far more comfortable sleeping at home than here at the hospital.

"But, as we discussed earlier, I'm an Intern, so I need to discuss this with my mentor to confirm my findings. That said, if you prefer, I can call a cardiologist who'll examine you and decide between those two options. Generally speaking, with your symptoms, cardiology would give the same opinion I just provided. But before you decide, I want to at least discuss this with my mentor."

"Thanks for the total honesty," he said. "So far, you seem to have done everything right."

"Thanks. Al, you can come with me to present to Doctor Gibbs. I don't believe Mr. Nylander is at any immediate risk."

Kellie moved to check Mr. Nylander's IV while Al and I headed to the Attending's office to see Doctor Gibbs. I presented the case and my recommendation.

"I think you're right," she said. "Will the patient accept being streeted with a referral?"

"Yes. I discussed the two options before I came to present. I did state that I would call a cardiologist if he insisted, but he didn't seem inclined to do that. Al watched the monitor for a good twenty minutes and saw nary a blip. All symptoms resolved with nitro and ASA, as I mentioned. I'll street him and tell him to take a daily low-dose aspirin until he sees his personal physician."

"Approved."

I handed her the chart, she made some notations, signed it, and handed it back.

"Al," Doctor Gibbs said, "run me through how you'd deliver this information to the patient."

"Well, given Doctor Mike already suggested the course of action, I think simply saying that we confirmed our diagnosis with you, and we don't believe he's in danger of an immediate heart attack. As such, he should follow up with his personal physician as soon as possible, and see a cardiologist. I'd advise him to take a daily low-dose aspirin tablet until told otherwise by his doctor or a cardiologist, and if he experiences further symptoms, he should call 9-1-1. And lay off the Taco Bell."

"Good job. Mike, you deliver the diagnosis and treatment plan."

"Will do," I replied.

Al and I left and returned to the treatment room to advise Mr. Nylander, and he, as I had been positive he would, accepted the plan of seeing his doctor and a cardiologist. While I filled out the discharge paperwork, Al disconnected the EKG and pulse oximeter, then removed the IV. I went over the discharge instructions with Mr. Nylander, referred him to the cardiology practice in the nearby medical building, then directed him to Patient Services.

"Thanks, Doc," he said. "I appreciate you explaining everything."

"You're welcome."

After Mr. Nylander put on his shirt, Al escorted him to Patient Services, and I checked with Nate, who said that the orderly had taken Julie for her x-rays. Al and I went to the lounge to get coffee, and I saw Krista on the couch reading a textbook.

"Let me know when you're ready for your quiz," I said to her as I poured myself a mug of coffee.

"High-speed, head-on MVA coming in," Ellie said from the door to the lounge. "Ghost asked for you to join him. Three minutes out."

"Be right there," I replied. "Krista, your choice if you want to keep studying or join us. Al, let's go."

I didn't wait for Krista's decision, as I didn't have time to debate or discuss it, and only she could save herself at this point. Al and I quickly left the lounge, put on disposable trauma gowns and gloves, and headed for the ambulance bay where Ghost, Angela, and Matt, a Fourth Year, were waiting.

"Where's your other student?" Ghost asked.

"Studying the procedure for RSI, as directed," I replied.

"Let's chat after this trauma."

"OK."

"Matt, intubate; Al, EKG and monitor, then Foley. Angela, full trauma panel; Mike, evaluate lower extremities and be ready for a pneumothorax or hemothorax."

Everyone acknowledged his orders and a minute later, the EMS squad rolled to a stop in front of us and Bobby hopped out.

"Male, nineteen; high-speed, head-on MVA; belted; tachy at 120; BP 80 palp; PO₂ 93% on ten liters; severe crush injuries to both legs; severe hematoma left temple; facial and left arm lacs; GCS 7; 5mg morphine; IV saline TKO."

"Trauma 1!" Ghost ordered.

With that blood pressure, he was most likely bleeding internally, though it could also be an effect of the morphine they'd given him.

"Single car?" I asked as we hurried into the trauma room.

"Two," Bobby replied. "Other driver exsanguinated on site."

In the trauma room, we moved the patient to the trauma table, and everyone got to work.

"Tube is in!" Matt announced.

"Good breath sounds right and left," Ghost announced.

"V-tach!" Al announced. "Pulse 140, BP 70 over unmeasurable, PO₂ 93%."

"Compound fracture right tibia," I called out. "Crush injury left tibia. Need an ortho consult."

"Foley is in," Al announced. "Blood in the bag."

"Belly is rigid," Ghost said. "He'll need an ex lap before ortho. Al, get the ultrasound for Mike."

Five minutes later, having confirmed free fluid in the patient's abdomen, we were on our way up to the OR. I wasn't invited to scrub in, so Al and I returned to the ED. I poured out the cold cup of coffee, refilled it, and Krista said she was ready to explain the procedure for Rapid Sequence Intubation.

She went through the procedure sufficiently well that I felt I could try to talk her through an intubation. I drank my coffee, then went to check Julie's x-rays. I saw a cyst just below her knee that was most likely the cause of her problem, which made resolving it simple, and the only possible complication would be if the cyst were malignant. I called Lucy Vandenberg, and she came down to review the films.

"I agree," she said. "That cyst is absolutely the cause of her symptoms. It's outpatient surgery and a general surgeon can do it because it's pressing on the nerve, not involving it. Street her with a referral to the outpatient clinic."

"Will do. Thanks, Lucy."

"Good job reading the x-ray."

"Thanks," I replied.

"If you ever want to do REALLY challenging work, come see me when you pass your general surgery boards."

"I like adrenaline far too much to do neuro! And I have to feed my caffeine addiction. That doesn't bode well for rooting around someone's brain with surgical instruments!"

Lucy laughed, "That is the one thing I miss, but you're right."

She left and Krista, Al, and I went to see Julie.

"You have a cyst," I said. "Let me put the x-rays up on the light panel and I'll show you."

I went over to the panel and showed her the small cyst just behind the lower portion of her knee.

"That's it?"

"Yes. You'll need surgery to remove it, but it's an outpatient procedure. I'll write you discharge orders, and you can go down the corridor, through the main lobby, and about thirty feet down the next corridor. That's where the outpatient center is. The nurse there will schedule an appointment for you."

"What do I tell her?"

"I'll give you a referral sheet that has the details. Give it to the nurse and she'll explain everything to you and get you onto the schedule."

"Thanks very much," Julie said. "Can you tell me what caused the cyst?"

"The surgeon and the pathologist who'll examine it after it's removed are best suited to answer that question. The x-ray really doesn't tell us more than that it's there and how big it is."

I sat down and wrote out the referral form for Julie's outpatient procedure, then filled out the discharge form. I handed her both, advised her she could take Tylenol or Advil for any discomfort, and then directed her to the outpatient clinic. Once she was on her way, I suggested to Krista and Al that they take their meal break, and I went to find Ghost. We went to the temporary Resident's office, and he shut the door.

"What happened with Krista?" he asked.

"Right before you came into the first MVA, I was going to talk Krista through an intubation and she didn't know what the 'sniffing position' was."

"Oh, for Pete's sake!" Ghost exclaimed. "She's a Fourth Year halfway through her trauma Sub-I!"

"I realize. I partly blame myself, because I should have asked as soon as I saw how light her procedure book was. After she observed the surgery on that MVA, I instructed her to take a break, get her textbook, and memorize the steps for Rapid Sequence Intubation. When Ellie let me know about the most recent MVA, I gave Krista an option of studying or joining the trauma. She chose to study, and when I asked after the trauma, she could repeat the steps sufficiently to be guided through them."

"You may not want to hear this," Ghost said, "but not everyone who wants to be a physician is cut out to be one. Krista is not. I know you think she's a reclamation project, but I honestly don't believe she can be reclaimed. You spoke with Leila Javadi and you saw Krista's procedure book and you've heard about her previous reviews. Do you feel she's qualified to be a doctor?"

"I think the correct answer is I'm not ready to say she's not. "

"How would you rate her?"

"Ask me in a five weeks."

"She's had three weeks, Mike. I don't believe she's going to turn it around. I know you're predisposed to see the good in everyone, and that's admirable, but our evaluations are not about finding the good, or giving someone the benefit of the doubt. I've heard the same things about Krista from Doctor Baxter and Doctor Billings, as well as Doctor Gibbs. You've heard it from Doctor Gibbs, Doctor Javadi, and you've seen her procedure book. Is it, as she says, that everyone is out to get her, or is she just not cut out to be a physician?"

"I believe that too often opinions are formed and become self-fulfilling prophecies. For every Tim Burg, there are three or four Felicity Howards, and the ratio might even be greater."

"So all of us are wrong, and Mike Loucks is right?"

"As you pointed out, I'm predisposed to see the good, and to believe everyone can be saved. That translates into believing people can be successful in their endeavors with proper support and encouragement."

"Let me know when the Reds put you into a game as a reliever instead of John Franco, or the Bengals bench Boomer Esiason, so you can start. Or, given your predilection for hockey, when Mario Lemieux steps aside so you can play. Or, to switch professions, when President Bush asks you to take command of the USS _Nimitz_."

"Interesting analogies, but there's a major flaw. Were I a AAA minor leaguer, a college Senior starting for Ohio State, or the XO on a carrier, _then_ the analogy would actually work, because I'd be basically qualified for those roles, similar to having an undergrad degree in biology, having scored well enough on the MCAT to get into medical school, and having passed step 1 of the MLE. Neither you nor I could walk onto a ball field and make a team any more than a High School Senior could walk into the hospital and be a Sub-Intern."

"Then assume you _are_ in one of those roles — playing AAA ball for the Nashville Sounds, the Reds farm team. Does that guarantee you'll _ever_ make it to the Majors? And if you do, that you'll ever be a starter? Or, in Franco's case, a closer? Would winning the Heisman Trophy twice guarantee you being a great NFL player? Or would being XO on a carrier guarantee you command?"

"Archie Griffin?" I asked.

"Decent rookie year, but then four years without a touchdown and only mediocre stats."

"But he _did_ make the NFL!" I countered.

"And yet, by all evidence, didn't belong there, despite being one of the greatest college football players of all time, and the only one to ever win the Heisman Trophy _twice_. That is, in fact, an excellent parallel — great undergrad performance, good MCAT, good classroom work, and passing step 1 of the MLE, but then flaming out.

"Allowing for the differences between sports and medicine, that is _exactly_ what is happening here. We're the equivalent of scouts, evaluating players and determining which ones we want to draft, hoping to get the best possible prospects onto our team. The difference is, we don't have minor league teams to which we can assign our draft picks. They have to be starters from the moment they're drafted.

"And let's compare to a specific known quantity. Think back a year to your first trauma Sub-I. You were trusted to do things usually reserved for Interns. And that was true of every member of your study group. I'm going to ask a question and I want a completely honest answer from you, without any qualifications — would you have accepted Krista to your study group?"

"Yes," I replied. "Unequivocally. The problem with her is NOT academics or book knowledge, but clinical skills."

Ghost smiled wanly, "I walked right into that one."

"You did," I replied.

"Then forget I even asked that question! But the point remains — she is not ready to call up to the majors. Of your six students, across all your shifts, where would she rank?"

"Last," I replied.

"And if you had to decide between Al and Krista for a procedure, which one would you _trust_ to do it?"

"Al," I replied.

"Think about that, Mike. He's a Third Year in his second rotation. Krista is a Fourth Year in her _eighth_ rotation. I understand you rooting for the underdog and believing in the innate goodness of every individual, but in the end, that's not what we're about. We're about saving lives. Can Krista _save_ a life? You certainly could as a Fourth Year, as could Clarissa, Maryam, Fran, Peter, and Nadine. Krista probably belongs in research, if she wants to stay in the medical field."

"Is it Doctor Gibbs' intention to give her a failing grade?" I asked.

"I think that is the only way to send a clear message that she should consider her alternatives."

"She believes she's being treated unfairly."

"Do _you_ think that's the case? Have _you_ treated her unfairly?"

"I'm dissatisfied with how the Emergency Department has handled this," I replied.

"But was it _unfair_, or was it a reflection of her skills and abilities, or lack thereof? And it's not just the ED, Mike. YOU immediately noticed her procedure book was seriously deficient, and took it upon yourself to speak to Leila Javadi to get another opinion."

"Krista still has five weeks to improve," I countered.

"That's true, but do you _really_ believe she can do that?"

"It doesn't matter if _I_ believe it; it matters if _she_ believes it and acts on that belief."

"And yet, in the end, what she thinks is of only passing interest. It's the judgment of Attendings and Residents that matters. If she can't convince _us_, she has no future in clinical medicine. You and I discussed that early on — now it's _her_ turn to ask for admission to the guild. You made the point, time and again, you had to satisfy _us_ to be invited in, and you made damned sure you did, as did your friends. Hold her to the same standard as you hold yourself, which is, as you and Father Nicholas have pointed out, the entire point behind the 'do not judge' command Jesus gave."

"This is where I'd use a specific Russian word with Clarissa!" I chuckled.

"I'll probably regret asking, but which one?"

"«мудак»," I replied. "It means a-hole. And is said in a tone that conveys my displeasure with my own words being turned on me. Which, of course, is what pissed off the religious leaders in Jesus' time. And the jury that tried Socrates."

"I believe the correct response is to say 'Physician, heal thyself'."

I smiled, "«Ατρέ, θεράπευσον σεαυτόν». Or, perhaps you prefer _Medice, cura te ipsum_."

"Fucking showoff!" Doctor Casper said, shaking his head.

"I try," I chuckled. "Though I did stoop to quoting Jerome, who did almost as much damage as Augustine of Hippo when it comes to what passes for Western Christianity."

Ghost laughed and shook his head, "I should have known the latent theologian would make an appearance."

"Hey, YOU quoted the Scriptures, so what did you expect? That said, it is an ancient proverb, and a similar phrase was used by Aeschylus in the 6th century BC."

"OK, how in Loki's name do you know that?!"

"The Norse God of chaos, also known as the trickster," I replied with a grin. "He could be my patron! It came up in my reading when I was studying to be a catechist. The Greek and Latin I quoted are directly from the New Testament — the ancient Greek text and Jerome's Vulgate. The reference to Aeschylus, along with similar Hebrew proverbs, was in a commentary on Luke's Gospel."

"And you know Loki!"

"A course in world religions at Taft taught by a Roman Catholic priest, who also taught Latin."

There was a knock at the door and I reached over and opened it to find Ellie.

"EMS two minutes out with an MI for you, Ghost," she said. "Mike, Doctor Varma needs help with walk-ins."

"Thanks, Ellie," Ghost said. "Let's get to work, Doctor!"

"Ellie, is Kellie available?" I asked. "My students are on their meal break."

"I'm available!" she said with a wink.

I chuckled, "Nice try, but I'd need trauma services if I took you up on the true intent of that offer."

"Kellie is all yours!"

"Thanks."

I went to the clerk's desk and grabbed the first chart in the rack. I scanned the chart for the thirty-six-year-old woman, which showed pulse, BP, and PO₂ were all in range, temperature slightly elevated at 99.9°F, with the only complaint being lower-left quadrant pain. I checked the board for an available room, wrote the patient's last name on it, then Kellie and I went to the waiting room and I called out for the patient, Ms. Collins. She identified herself, and after I introduced myself and Kellie, we escorted Ms. Collins to Exam 3.

"What brings you to us today?" I asked.

"A sharp, shooting pain in my lower back which seems to spread to my, uhm, lady parts."

I almost laughed, but managed not to. There were plenty of people who were prudish about their bodies, and that often led to the use of euphemisms.

"Is it constant?"

"No. It's not regular, as in, like once every hour, but when it hurts, really hurts and last for maybe forty minutes."

"Does it occur in some relation to your meals? Say, two hours after a meal or some regular pattern like that?"

"No."

"What about in relation to having a bowel movement or emptying your bladder?"

"Not that I've noticed."

"Any constipation?"

"No."

"Do you eat a lot of nuts or seeds?"

"No."

"Is there any chance you could be pregnant?"

"Heavens no! I take my Pills religiously!"

"Let me rephrase that question — have you engaged in intercourse since your last period?"

"Yes."

The most likely differential diagnoses were, in order, diverticulitis, kidney stones, bowel obstruction, ovarian cyst, or ectopic pregnancy. Less likely were appendicitis or gallstones, as those typically had right-side pain, not left. Of course, there were other potential causes, but those were the ones I'd need to rule out.

"I'm going to have Kellie draw some blood and get a urine sample, then I'll do an exam."

"What do you think is wrong?" Ms. Collins asked.

"The list of possibilities is fairly long," I replied. "And most are easily treatable. Let's see what the exam and test results show, then we can discuss the potential cause."

"OK."

"Kellie, CBC, Chem-20, pregnancy test, and basic urinalysis."

"Pregnancy test?!" Ms. Collins gasped. "Why?"

"Because the Pill, even with perfect use, is not a guarantee. Your OB/GYN should have discussed that with you. The failure rate for the Pill is reported multiple ways, but the one I think best reflects the situation is that over the course of their lives, one woman in a hundred will become pregnant while using the Pill. Another statistic is that the pregnancy rate for women on the pill is about 3 in 1000 per year."

"That is the LAST thing I need," she sighed.

"Kellie will take you to the restroom so you can provide a urine sample, then bring you back and draw a few tubes of blood. I'll be back in about five minutes."

She acknowledged me and I left the room and went to the lounge, where Al was studying his trauma textbook.

"Is Krista at the triage desk?" I asked.

"Yes. We came back about a minute ago. I just sat down. I saw you had a patient on the board, but didn't want to interrupt."

"It's OK. You just come to the exam room and let me know you're back. If there's a reason for you not to come in, I'll tell you."

I filled a paper cup from the water cooler, downed it, then sat down to relax for a few minutes, and give Kellie a chance to take care of the blood draw and urine sample. Just as I was about to get up, Kellie came into the lounge.

"Ms. Collins' urine sample had a slight pinkish tinge," Kellie reported.

I nodded, "Hematuria is a sign of kidney stones, which was my second option after diverticulitis. Let's go do the exam."

Kellie, Al, and I returned to Trauma 3, and after introducing Al as my student, I performed a physical exam on Ms. Collins, finding tenderness at her costovertebral angle, which was between her twelfth rib and her vertebral column. That was the area of her kidney, and was further indication I was on the right path.

"Al, would you get the portable ultrasound, please?"

"Right away, Doctor!" he said, then left the room.

"I strongly suspect you have kidney stones," I said to Mrs. Collins. "While we're waiting for the blood test results to come back, I'm going to do an ultrasound to rule out an ovarian cyst."

"Kidney stones? What causes that?"

"There are a number of things, including genetics and diet. Once we have the blood work back, and I see the ultrasound images, I'll refer you to a urologist."

Al returned with the ultrasound machine, and I checked for cysts, and for completeness, ectopic pregnancy, then searched for the kidney stones. I wasn't able to locate them, but ultrasound wasn't the best way to see them; a CAT scan would be much better for that purpose.

"No ovarian cysts," I said. "Your lab results will be back in about thirty minutes. Just relax until then. Are you in pain now?"

"Yes, but it's not terrible."

"We'll get you something for that. Kellie, 600mg ibuprofen, please."

The three of us left the room, and while Kellie went to get the medication, I checked with Doctor Gibbs and took my meal break. I went to daycare, picked up Rachel, and then went to meet with Antonne, Paul, Julius, Jordan, Conchita, and Danika. As I expected, Conchita asked to give Rachel her lunch, and when Rachel didn't object, I agreed.

We had a nice lunch and caught up on what they had done during their Summer break. When we finished, I took Rachel back to daycare, then returned to the ED just as Al was bringing back the test results for Mrs. Collins. Everything looked normal except a small amount of blood in her urine and a slightly high calcium level, both of which tended to confirm my diagnosis. I presented to Doctor Gibbs, and after she signed the chart, I discharged Ms. Collins with a referral to a urologist.

The afternoon was relatively calm, with a series of fairly mundane walk-ins, and at 6:15pm, I met Kris and Rachel in the cafeteria for dinner.

"Is everything still the same as we discussed for tomorrow?" Kris asked.

"The White Coat Ceremony is at 3:00pm. Loretta said I can leave at 1:45pm, so I plan to drive home, shower, dress, and get back to the ceremony to give my speech. The ceremony ends around 5:00pm. I'll leave then, come home to get you, and then we'll go to the Holiday Inn. Lyudmila is staying at the house with Rachel, right?"

"Yes. My parents will bring her to the house around 5:00pm and come get her at 11:30pm. How do you dress?"

"Shirt, tie, and medical coat. I rarely wear my medical coat, but that's the attire for the ceremony."

"To the banquet, as well?"

"No. I'll put on my suit coat for that."

"Is wearing my blue dress OK?"

"I prefer it on the floor next to the bed," I teased.

Kris laughed softly, "After the banquet! Though we should probably hang it up."

"Oh, I suppose…" I replied with faux resignation.

"How was your day? she asked.

"Fairly typical, mostly walk-ins, but a pair of MVAs — auto accidents. I was able to scrub in on one of the surgeries and was allowed to hold a retractor."

"I find it so strange that you and your friends are so excited about something so easy and simple!"

"Because it's the first step. If you're trusted to do that, you'll be trusted to do more. It's how things started with every procedure I'm allowed to do — simple things like drawing blood, hooking up EKGs, putting in Foley catheters, and so on. You build on each step, gaining experience and earning trust. That's why I'm mostly left to work independently, though I do have to present cases to Attendings and gain approval in most instances."

"Daddy?" Rachel said.

"Yes?"

"Daddy home?"

"Daddy can't come home tonight," I said. "He has to help sick people."

She pouted, but there wasn't anything I could do about it. On the plus side, in a week, my shift would change, and I'd be home every night. If Rachel were a bit older, she might understand the concept of a week, and I couldn't even use 'sleep times', which I'd heard people use, as Rachel napped in the afternoons.

"She misses you," Kris said. "I do, too, but I made the deal."

"Fortunately, we're going to eighty hours maximum, and I'll be home every night. We'll just need to adjust her sleep schedule because I won't be home until about 9:30pm on Mondays, Tuesdays, and Thursdays. I'll be home by 5:30pm the other nights."

"We should find some time on Sunday to sit down with your new schedule and figure that out," Kris observed.

"We should," I agreed.

We finished our meal, and I walked Kris and Rachel out to Kris' Tempo. I kissed them, told them I loved them, then headed back into the hospital for the remaining twenty-three hours on my shift.

_August 25, 1989, McKinley, Ohio_

"Did you get any sleep?" Clarissa asked when we met for breakfast on Friday morning.

"About seventy minutes total," I replied. "I think half the county decided it was the perfect night to call 9-1-1."

"And you have the alumnus speech and the banquet to go to."

"I'll manage. I can sleep in tomorrow. I let Kim know I wasn't going to make band practice."

"How are you guys working that?"

"I'm going to practice at home by playing for Rachel. We'll have one group practice session before each concert, probably on the Friday evening before the concert. It's not a perfect solution, but it'll work. How was Medicine last night?"

"You should know!" Clarissa replied. "You sent me three last night all by yourself!"

"I have to move them out somewhere! Either admit or street. No sleep?"

"About two hours in thirty-minute stretches, because SOMEBODY kept waking me up!"

"Poor baby!" I teased.

We finished our breakfast, then headed back to our respective services. Serenity, Walt, and I had a busy morning, mostly handling walk-ins, but also admitting one rule-out MI for an angioplasty. Just before noon, Doctor Gibbs asked to see me.

"I heard from Ghost you had a conversation about Krista, and he said you expressed concern about how we're teaching her, or rather, not teaching her."

"It's my opinion that so long as a student is part of the program, we should spare no effort in training them to be physicians."

"Even if they're unqualified?" Doctor Gibbs asked.

"If they were truly unqualified, they wouldn't be here. Or are you saying that people receive passing grades even when they're unqualified?"

"Not from me, they don't."

"Which doesn't address the question I asked in the way you know I meant it. If she was truly unqualified, and it appears some people think she is, then why did she not _fail_ her rotations, especially in Cardiology? There's a difference between being sub-par and being unqualified."

"Are you arguing we should accept sub-par candidates merely because they want to be physicians?"

"Not at all," I replied. "I wouldn't accept her for the Match, that's for sure. But that's a very different thing from saying she's unqualified. As I pointed out to her, her procedure book tells a story that will make her Match options extremely limited. She has roughly five weeks to rectify that."

"And if she doesn't?"

"Then the system will work. My argument is that she should at least be given the opportunity to improve."

"And do you think she will?" Doctor Gibbs asked.

"As I said to Ghost, what I think isn't particularly relevant. What Krista thinks is all that matters. If _she_ doesn't think she can improve, then it's 'game over'. If she does, and cannot, then she receives either a below-average grade or fails. If she does improve, then we've achieved our mandate to teach. Let me ask this — what's the goal of assigning her scut for the next five weeks? To punish her? To encourage her?"

"To protect our patients and to allow us to expend our limited resources on training students who we feel are far better candidates. You admitted to Ghost that Al is much better."

"I did, but I'm judging him as a Third Year. And I'd like to point out the number of times someone had to lecture me, whack me with a rolled-up newspaper, or otherwise correct me."

Doctor Gibbs smiled.

"And each and every time it was either pulling back gently on the reins to keep you from bolting, a disagreement on the application of limited resources, or about philosophy of care. Never once did anyone have to talk to you about your clinical work. And I don't mean your bedside manner, because in a perfect world, we'd all have time to do it that way.

"Think about the difference — you were _so_ good that we had to rein you in so that you didn't make a career-ending decision because your heart was in the right place, but you didn't have the experience to know better. I was the same way. So were Ghost, Gabriel, and Nielson. Those are all physicians you look up to and respect. Tell me, privately and not for repeat outside this office, what you think of Doctor Varma."

"A competent trauma specialist," I replied.

"Those are damning words from you, Mike! Now compare him to Krista. Is there _any_ comparison? They're only one year apart, and I'd lay serious money on you believing she's not even _competent_ at this point. And I'd make an equally large bet that you'd say that Al _was_, Third Year or not."

"I didn't mean to denigrate Naveen. He's a good doctor."

"Yes, he is. Would you compare him favorably to Leila Javadi, Shelly Lindsay, or Carl Strong? Or is he good and they're great?"

"I understand what you're getting at, but I don't see Krista as a lost cause. She could be a competent doctor and there is a need for competent physicians."

"Listen to what you're saying," Doctor Gibbs counseled. "'Could be' says you have concerns."

I shook my head, "I didn't mean it that way. And you, and others, said things similar to that about me. That I had the potential to be a great doctor."

"Let's say we do it your way, and in a week, when schedules change, the paramedic training program begins, and she's assigned to someone else for most, if not all of her shifts, what happens?"

"Isn't that up to her? Our obligation is to train her. Her obligation is to learn. I've explained that to her and pointed out what she needs to do. Why not give her a chance?"

"What do you think we've been doing?" Doctor Gibbs asked. "And remember, Kayla Billings has Krista for twelve hours, just as you do, and I've sought her input as well.

"You're concerned that I would back up Krista's claim of being treated unfairly, and that would create a firestorm."

"That was suggested by at least one person."

"Ghost, of course, as he's the only one with whom I've had an in-depth conversation about Krista in the past two weeks. My answer, to any inquiry, would be factual and be about observed events, not about what I felt someone was thinking. In other words, I'd only speak to things I _knew_ and could back up, not to questions about what someone else might be thinking. That's how I handled the situation with Melissa Bush."

"And when you're asked if you think Krista was treated fairly?" Doctor Gibbs asked with an arched eyebrow.

"I could rightly say that I gave her every opportunity, but can't say anything about what anyone else had done. You haven't told me to stop trying to teach her, though you did suggest she be what you've called a 'scut monkey', similar to how Doctor Rafiq was treated by surgery."

"Do you think that was justified?" Doctor Gibbs asked.

"He was a terrible teacher," I replied. "And had a bad attitude. Doctor Cutter and Doctor Roth felt he needed to learn a tiny bit of humility and change his attitude. But the way they treated him wasn't out of line for how surgeons are typically treated before they reach PGY3."

"And is Krista's treatment out of line for a below-average student? Something you immediately recognized simply by looking at her procedure book?"

"Out of line? No. The correct way to do things? Also no."

"You're still a pain in the ass, Loucks."

I chuckled, "So I've been told."